Skip to main content

“I do not know the advantages of having a general practitioner” - a qualitative study exploring the views of low-acuity emergency patients without a regular general practitioner toward primary care



Emergency departments (ED) worldwide have to cope with rising patient numbers. Low-acuity consulters who could receive a more suitable treatment in primary care (PC) increase caseloads, and lack of PC attachment has been discussed as a determinant. This qualitative study explores factors that contribute to non-utilization of general practitioner (GP) care among patients with no current attachment to a GP.


Qualitative semi-structured telephone interviews were conducted with 32 low-acuity ED consulters with no self-reported attachment to a GP. Participants were recruited from three EDs in the city center of Berlin, Germany. Data were analyzed by qualitative content analysis.


Interviewed patients reported heterogeneous factors contributing to their PC utilization behavior and underlying views and experiences. Participants most prominently voiced a rare need for medical services, a distinct mobility behavior, and a lack of knowledge about the role of a GP and health care options. Views about and experiences with GP care that contribute to non-utilization were predominantly related to little confidence in GP care, preference for directly consulting medical specialists, and negative experiences with GP care in the past. Contrasting their reported utilization behavior, many interviewees still recognized the advantages of GP care continuity.


Understanding reasons of low-acuity ED patients for GP non-utilization can play an important role in the design and implementation of patient-centered care interventions for PC integration. Increasing GP utilization, continuity of care and health literacy might have positive effects on patient decision-making in acute situations and in turn decrease ED burden.

Trial registration

German Clinical Trials Register: DRKS00023480; date: 2020/11/27.

Peer Review reports


Many countries record rising numbers of patients in emergency departments (ED) [1, 2]. A substantial share of these ED consulters present with low-acuity care needs and could potentially receive a more suitable treatment in primary care (PC) [3, 4]. Concerning these cases, achieving a shift toward a more appropriate use of general practitioner (GP) care could benefit not only the patients concerned but also the entire ED care system, as crowded EDs are associated with poorer quality of care [5].

The use of ED care for low-acuity complaints is influenced by multiple factors. Among others, a lack of knowledge about alternative acute care options was identified [6, 7] and attributed to a lack of health literacy [8, 9]. There is evidence that lower levels of heath literacy are associated with higher subjectively perceived treatment urgency [9]. In this context, GP care has been advocated not only as an adequate alternative treatment option for low-acuity health issues but also as an important source of health information and facilitator for care coordination, helping patients navigate in the sometimes complex structures of the health care system [10, 11]. Consequently, it is assumed that patients with no continuous GP attachment are more likely to visit the ED for low-acuity care needs [12]. Integrating GP care by reducing access barriers could reduce demand for ED services by both providing a fixed first point of contact and promoting continuity of care, which in turn facilitates the management of long-term health care needs [13,14,15,16].

With regard to these findings, it is problematic that every tenth person in Germany has no GP [17]. In our health care system, there is no obligation to register for GP care at a practice and attachment is completely voluntary. Patients are free to choose or change providers anytime, and anyone can likewise visit the ED at own discretion without following any gatekeeping procedure [18]. Having the current absence of regulations and patient steering in mind, it is important to explore the roots of lacking PC integration. This is a prerequisite for the development of concepts to promote attachment and thus to potentially influence future ED utilization behavior [19]. Accordingly, our research questions for this qualitative interview study of ED patients without current attachment to a GP were as follows: What factors are associated with their health care utilization behavior and non-utilization of GP care? Which views and previous experiences of GP care could contribute to GP non-utilization and lack of attachment?



This qualitative evaluation was conducted as part of the multicenter mixed-methods study EMAPREPARE (Emergency and Acute Medicine– Primary Care Demands in Patients Resorting to Emergency Departments), which is a subproject of the research network EMANet (Emergency and Acute Medicine Network for Health Care Research Berlin). EMAPREPARE explores the redirection potential of low-acuity ED patients without a GP. The project includes a pilot intervention and complementary qualitative interviews. The results and implications of the intervention have been reported in a previous publication [20]. Our paper presents findings on participants’ views and experiences of GP care from the qualitative interview study accompanying the intervention. The core team of researchers for this project consisted of L.K. and S.O. (female health scientists), F.H. and C.H. (male general practitioners and senior researchers), and R.R.C. (female ED physician). The EMAPREPARE study was registered a priori in the German Clinical Trials Register (trial registration number: DRKS00023480, registration date 27/11/2020) [21]. Qualitative data are reported in this article according to the COREQ guidelines (Additional file 2) [22].


Interviewees were selected as a subsample of the EMAPREPARE cohort. Recruitment was conducted in three inner city EDs in Berlin, including two university medical centers. Patients were recruited in the ED waiting room, informed about the project’s aims, and asked for written informed consent to participate in the study and an optional qualitative interview. Consent included audio recording, storage and pseudonymized analysis of the interview material. The EMAPREPARE inclusion criteria needed participants to be of age (≥ 18 years) and fluent in German. Patients also had to be self-referred walk-in outpatient cases, triaged in the Manchester Triage System (MTS) lower priority categories 3–5 [23]. A further eligibility prerequisite was that patients did not have a regular GP, meaning no current self-reported attachment to a particular practice, or regular recent visits. Patients were excluded if they were not able to formally give informed consent. Researchers had no relationship with the participants prior to the study. The patients’ reasons for refusing to participate in the study were not recorded.

Recruitment for the interviews was based on the principle of purposive sampling [24]. We tried to balance gender and intentionally over-represented participants willing to make use of the GP appointment service, which was part of the pilot intervention. Further information on sampling details can be found in a previous paper [20]. Patients who consented to a qualitative interview were called after ED discharge to schedule an interview appointment within two weeks after ED presentation to facilitate recall.

Data collection

A semi-structured interview guide based on the literature was compiled with the intention to capture and understand patients’ views and experiences [25]. The questions were thoroughly discussed within the study team and in an interdisciplinary methods working group at the institute, and pilot tested in two interviews. After the first two interviews, the guide was revised further. The final interview guide consisted of three parts (see Additional file 1 for complete interview guide). The results presented here correspond to the first part of the interview guide, which addressed patients’ experiences and views about GP care (see Table 1), while parts two and three covered participants’ views on the EMAPREPARE intervention, with results reported elsewhere [20]. During the interviews, questions were individually adapted to the conversation flow.

Table 1 Excerpt of the interview guide’s questions

Interviews were carried out between March 2021 and January 2022 by L.K. and S.O. by telephone (to avoid COVID-19 infection risk) and were concluded after thirty-two interviews once no more new themes emerged, indicating content saturation [26]. The interviewees did not receive any questions in advance, and interviews were conducted only once with each patient. Interviews were audio-recorded, and field notes were taken to document additional impressions or specifics of interview circumstances. Recordings were then transcribed verbatim and pseudonymized by L.K. and S.O., the transcripts were not returned to the patients for corrections and/or comments.

Data analysis

The transcripts of the interviews were analyzed by qualitative content analysis according to Mayring using a combined deductive and inductive approach for coding text segments. This interpretative but rule-guided process is based on coding guidelines. The method allows focusing on essential interview topics and facilitates thematic structuring and summarizing of the content [27]. Due to the exploratory nature of the study, no pre-existing framework was used to guide analysis. The first draft of the coding tree was based on the themes of the interview guide, and additional themes were then inductively derived from the material during coding. This allowed for consideration of both theoretical aspects and interview content. All derived codes had defined coding rules and anchor examples. Transcription, coding, and data analysis were performed in MAXQDA 2020. The majority of interviews were independently coded by two scientists (L.K. and S.O., experienced in qualitative research) to enable comparison and discussion of discrepancies. As interviews were conducted in German, quotes were translated to English by the authors for presentation in this paper.


Sample characteristics

Thirty-two interviews were conducted. An overview of the participants’ characteristics is given in Table 2. The interviews had a mean duration of 20 min.

Table 2 Characteristics of interviewees (n = 32)

After categorizing the interview data, diverse factors contributing to the non-utilization of GP care emerged. These factors were in turn associated with thematic categories related to patient characteristics and underlying views and experiences with past GP care (see Table 3). In the following, these thematic categories are presented in detail with exemplary interview quotes.

Table 3 Factors contributing to non-utilization of GP care: Thematic categories and subcategories

Patient characteristics related to non-utilization of GP care

Rare need for medical care

With regard to the reasons for the low relevance of GP care for their individual care context, interviewees most prominently described a rare need for regular medical care in the past due to their good state of health.

“There is no doctor I have consulted more than five times, except for my gynecologist.” (P23).

“So, I have not really been ill until now and therefore I do not have a GP I regularly visit.” (P20).

Distinct mobility behavior

Apart from the rare need for regular medical care, many patients attributed the lack of continuity in their GP utilization patterns to attachment difficulties rooted in their individual mobility patterns.

“Before I came to Germany, I had a GP, but since I moved, I no longer have a GP.” (P28).

“I have simply moved too often. Quite often within Berlin, in different cities, abroad.” (P1).

“My parents still have the same GP that I had as a child. That has changed in modern times because people are much more mobile and move around more often. You no longer stay in one place for twenty to thirty years and have all your doctors in the neighborhood for your whole life.” (P18).

Due to circumstances such as the aforementioned infrequent need for medical care and distinct mobility behavior, many participants depicted a rather situational consultation pattern with sporadic visits to various physicians based on short-term needs. In this context, a personal relationship and continuous attachment to a specific GP practice were frequently described as less relevant than solving acute health problems by consulting a doctor selected on an as-needed basis.

“There is a GP practice where I go when something comes up. However, I do not consider this my GP of choice.” (P26).

“Otherwise, I just do not have any relationship [to a GP] at all because I always just sat down in the acute consultation of some doctor. I described the problem and was treated once-off.” (P25).

“As I said, I do not really have a GP in the true sense. I have been to GPs here and there, depending on which district I was living in at the time, and whether it was an urgent matter or not” (P18).

Lack of knowledge about the role of a GP and health care options

Many of the interviewed patients reported a self-perceived lack of knowledge about the responsibility of a GP.

“I do not truly understand [what a GP does], I am of course familiar with the word though.” (P1).

“I do not know the advantages of having a GP. That is why I never truly thought about it.” (P26).

“It is probably good to have an overview of the types of occasions for which people go to the GP. […] because it is not at all clear to me, actually.” (P11).

Some interviewees explicitly mentioned this lack of knowledge about GP care as a factor that made it difficult for them to navigate the care system and find the right doctor for their specific health problems.

“Then it is difficult for me to say, if I have an issue with my ears, whether I should go straight to an ear, nose and throat specialist, or whether I should go to the GP first.” (P13).

“And it is not so clear to me now to what extent the tasks of the GP overlap or differ from the tasks of the respective specialists to whom I have turned thus far. If I were aware of what a GP actually does differently and how this could be of use to me, then I naturally would be open to it.” (P2).

In this context, one patient with a migration history depicted his limited understanding of German health care structures and the role of the GP within the system.

“Because I cannot understand the health system in Germany. It is very different from my country and completely ineffective. In my country you automatically have a GP. Everyone has.” (P28).

Views about and experiences with previous GP care

Little confidence in GP care

Several interviewees also attributed their low utilization of GP care to a lack of confidence in the skills and knowledge of GPs compared to other specialists.

“I always have such a bad feeling about GPs, so sorry about that.” (P4).

“From my experience, it is always the case that the normal doctors [GPs] are a little less experienced and can help a little less with acute cases. They can give great check-ups, they can give great recommendations […], little things like that. Unfortunately, this is not the case for acute cases. They have no experience.” (P4).

“I also understand that the GPs are often not extremely qualified here […], the specialists are usually much more qualified and I do not expect anything.” (P16).

Some patients also considered consulting a GP time-consuming, complicated, and a pointless additional step in the care process. In this regard, patients portrayed the GP as a mere intermediary to medical specialists.

“My general experience is that going through GPs just delays everything even more. However, that is probably a perspective you have as a young person.” (P11).

“I […] find it cumbersome to be sent from a GP to a specialist. It is an outdated concept for me.” (P25).

Preference of consulting specialists

Consequently, direct consultation with medical specialists was a pattern of utilization frequently depicted in the interviews.

“When I look back, whenever I went to the doctor, it was usually directly to specialists.” (P12).

“If I am concerned about a specific problem anyway, then I can also sit down in the emergency consultation hour of the specialist.” (P2).

In addition to the aforementioned view that GP care is an intermediary step to be bypassed, some patients explicitly expressed a belief in the professional superiority of medical specialists over GPs.

“Because I often have the feeling that when I go to the GP, he does not really know what to do either, and that I always end up with a specialist.” (P7).

Negative experiences with GP care

Regarding past contacts with GP care and their potential role in explaining current individual consultation decisions, some respondents described negative experiences. An important theme in this context was frustration about long waiting times for appointments and in practice.

“ […] I have also always experienced GP surgeries as very crowded.” (P3).

“You cannot always get to an acute consultation right away. You also have to wait.” (P25).

In addition, many participants described previous access problems, such as not being able to obtain a timely GP appointment, or futile attempts to find a practice that would accept new patients.

“I felt very rejected. I called different doctors’ offices and they said, “Do not come!” (P15).

“For three or four months I was looking for a GP, but the answer is always that they do not take new patients.” (P29).

Participants also reported that they had not been satisfied with the treatment they received in the past from the GP.

“When I think about my GP experience, they were less able to help me there.” (P21).

“Thus far, my experience has not been so good, which is why I went straight to the ED. When I had truly severe pain, they [GPs] only ever prescribed me painkillers.” (P27).

Some interviewees described experiencing GP care as impersonal, including the impression that the respective GP was overworked and did not take enough time for consultations.

“[…] because the GPs are so overburdened.” (P16).

“That is always so sobering, you ask yourself, has he [GP] truly listened to what you have to say? You tell him and he types on the computer and you get a prescription and that is it. This personal factor is also missing. It does not exist like that anymore.” (P19).

Views on the concept of having a regular GP

Participants interviewed were also asked what the concept of ‘having a regular GP’ implied for them. While most patients had a general idea of this, for some it seemed to be a completely foreign concept.

“So probably, it [having a regular GP] just means that someone has a regular doctor that they always go to.” (P1).

“I do not know [what it means to “have a regular GP”].” (P23).

“I do not truly understand it, the term is familiar to me, of course, and I have observed with my grandmother, for example, that she had something like a GP who actually also came to her home. In addition, she knew him for decades.” (P1).

Although some patients did not understand the concept or need for a GP, most interviewees indicated that they could see clear benefits from the continuity of GP-based care. Having a fixed contact person in case of illness who knows the individual medical history was frequently mentioned as the main advantage.

“To have a doctor where you can go if something is wrong and who also knows you and already has the data.” (P30).

“I would say someone who actually knows me. Someone I do not just go to when I have cut off my finger, but who actually knows my history and accompanies me like that. Maybe not through life, but at least for a period of life. Who can then perhaps also assess what the better treatment options are, because I have certain previous illnesses, or because they know that I take certain other medicines or have taken certain other medicines until recently?” (P6).


Summary of findings

In the interviewed sample of low-acuity ED patients without a regular GP, a number of central contributing factors for GP non-utilization and an associated lack of continuity of care were identified. Patients’ characteristics and lifestyles are linked to underlying views about PC and individual past experiences. In particular, a rare need for medical care due to good general health, mobility, and a lack of knowledge about the role and responsibilities of GPs and health care options were identified as important factors for GP non-utilization. Little confidence in PC providers emerged as a widespread view, possibly contributing to a preference for specialist care. Interviews suggested that this constellation is often due to negative experiences with GP care in the past.

Results in context

Implications of sample composition and study setting

Our study investigated factors that contribute to GP non-utilization in low-acuity ED patients. With regard to our interview sample, it is important to note that it consisted of relatively young patients, corresponding to the overall mean age of 30.6 years in the EMAPREPARE cohort. Regarding the prevalence of a first-generation migration history ( 30%), the qualitative sample likewise reflects the composition of the larger cohort from which it was recruited. The two mentioned sample characteristics have been identified in previous studies as factors that increase the odds of not having a GP [17]. Furthermore, previous work has described young age and not having a GP as factors contributing to low-acuity ED usage, which is also consistent with our findings [28, 29]. However, other population groups have also been identified as contributive to rising ED utilization, particularly older people and people living in nursing homes, which is not reflected by our results as to the selection criteria of the study [30].

The results might also reflect specifics of the urban study setting with a high availability of specialists and care choices, where patients are less tied to one provider and have many options, which may play a role in GP care utilization and attachment motives. Other studies also found that low-acuity ED patients in urban settings, compared to rural settings, are less connected to GP care [31] and show lower commitment to their PC provider [11].

Understanding utilization motives and potential implications

Need to adapt GP care to individual life situations and to diminish access barriers

Many of the comparably young patients from our cohort reported being rarely ill and having no regular need for medical care. Concerning age, findings by Tillmann et al. show that young people are often attached to a pediatrician during their childhood and might miss the transition to GP care as young adults. The authors stress the importance of improving this transition to support GP attachment [17].

Even though utilization of GP care was depicted as rare and sporadic in many interviews, some of the participants notably consulted a GP in the past 6 months (see Table 2). This utilization was prevailingly described as situational, with no attachment or long-term continuity. Accordingly, a qualitative study on the attachment of patients to GP practices by Frederiksen et al. highlighted that patients with higher morbidity and vulnerability have a greater need to have a regular GP [32]. This is consistent with our findings.

Against the backdrop of patient characteristics associated with non-utilization, such as young age, good health and related situational contacts with GP care, it is worth taking a closer look at negative experiences with PC depicted by the participants. Access problems (waiting times, appointment scheduling problems) play an important role in this context. Difficulties in obtaining a timely appointment at a GP practice were also described in a qualitative study from France by Durand et al. and identified as a reason for seeking low-acuity ED care [33]. Access problems may also be related to the problem of patient mobility, which in turn is a feature associated with younger age groups. For people who move between neighborhoods or cities, it might be quite burdensome to connect to a GP and to schedule appointments. The interviews describe experiences of rejection by practices, even for acute complaints. In a recent qualitative study, Korczak et al. investigated determinants of low-acuity ED presentations and found three main factors specifically associated with GP care: having no GP, failure to attend an appointment, and negative previous experiences with a GP practice. In turn, the main reason for not having a GP identified by this study was that patients move around or do not understand the health care system and the most appropriate care paths. The authors suggested that there should be services to enable patients to find a GP who meets their individual needs, arguing that this would increase GP attachment and continuity of care in the long term [34]. A targeted GP attachment program, as piloted in the interventional module of EMAPREPARE, could help to connect patients with GPs [20].

Another aspect underlying the deliberate non-utilization of GP care, which came up repeatedly in our interviews, was little confidence in GP care, which was related to negative experiences with PC in the past. In an Australian study, Wong and Hall examined how ED patients’ experiences with GP care affected their ED attendance and found that patients who had negative experiences with GP care in the past were more likely to visit the ED [35]. A general lack of trust in GP treatment can also play a role in ED utilization decisions [31]. Previous research by our study group has also stressed the potentially negative influence of GP-aversive views and negative PC experiences on utilization behavior [36].

Need for patient education

Patients often do not know where to access appropriate care for their needs, or struggle to obtain suitable medical attention. A surprising finding in our data was that many interviewed patients were not familiar with the role and tasks of a GP and the concept of having a regular GP practice. Even if these statements cannot be generalized – especially regarding other settings and populations – they could indicate a lack of health literacy in this patient group. While we did not survey health literacy in our study population, other works however have shown lower health literacy in low-acuity ED patients than in the general population [37, 38]. On that score, Strauß et al. found that health literacy in low-acuity ED patients was positively related to GP attachment. Therefore, they assumed that improving GP attachment among these patients would help them to receive personalized information from their GP about different health care options and therefore make more adequate ED utilization decisions [10]. Likewise, Oedekoven et al. stressed the importance of GPs as a source of health-related information [39].

In line with the theme that non-utilization of GP care is associated with knowledge deficits about the functions and potential of PC, our interviews indicated that beliefs about the professional superiority of specialists frequently seem to play a role in not having a regular GP. Promoting information about the role of GPs and their care capabilities seems crucial in this context. However, it is certainly a challenge to reach people who have no contact with PC. Himmel et al. suggested that– especially for younger patients who are frequently not attached to a GP– health insurance personnel could educate patients about the benefits of having a GP and continuity of care [40]. Other authors have likewise stressed that specific information on the importance of having a regular GP could help to increase patients’ commitment to PC [11]. For patients with utilization patterns that are detached from PC, the ED may appear to be a particularly attractive care pathway or may be perceived as without alternatives. A patient-oriented approach to promoting and improving health literacy is therefore important to support informed decision-making processes [9]. Altogether, we must stress that our results highlight the need to improve the public perception of GPs’ important coordinating role in the healthcare system as well as their medical expertise.

Attachment to a GP and continuity of care

Interestingly, our interviews revealed that many patients embrace the theoretical concept of having a regular GP and the associated advantages of having a health care provider who knows their medical history and is available as a point of contact for any medical problems that arise. However, translating this agreement in principle into actual utilization reality is not achieved, with barriers mentioned in our interviews likely playing a central role.

Numerous works have emphasized the link between continuity of care and potentially inadequate ED utilization, and promoting PC attachment appears to be a promising leverage point for streamlining utilization [41,42,43]. A study by van den Berg et al. showed that patients with regular GP attachment are more likely to consider PC as a primary care option in an acute situation [12]. Other works have stressed that in addition to continuity of care, the doctor-patient relationship plays a central role in the decision to either consult a GP or turn to the ED for a problem that is perceived as urgent [41, 42]. In line with this, Strauß et al. reported that both the quality of a GP-patient relationship and the experienced continuity of care are crucial factors in reducing ED utilization beyond mere attachment to a GP [10]. Our own research points in a similar direction [20]. Notably, the importance of continuity of care extends well beyond the acute care context, and some studies even suggest potential benefits in terms of mortality [42, 44, 45].

Our findings of a fundamental openness to attach to primary care in this patient group however raise the question of how this can best be promoted. The study’s approach is based on voluntary participation in an appointment scheduling service, but this is by no means the only conceivable measure. Internationally, many health care systems (e.g. Denmark) are based on mandatory registration with a particular practice, frequently associated with gatekeeping regulations [46]. Respective policy changes toward a primary care-based healthcare system could alleviate many of the issues raised in our study, with our findings suggesting that this could potentially be well accepted. However, as this was not part of our research question, further investigation is required.

Strengths and limitations

This qualitative study provides new insights into the views and experiences of low-acuity ED patients without PC integration toward GP care, and their complex reasons for non-utilization. While conducting our study, measures such as independent coding and reflection of results with independent researchers were taken to reduce interviewer bias, but such cannot be completely eliminated [47, 48]. Other caveats include possible bias due to social desirability among interview respondents [49] and selection effects related to patients who may have felt offended when approached by a project about redirection to a GP and the appropriateness of their visit, and therefore refused to participate in the study. A member check with interviewed patients was not performed. Furthermore, qualitative research is inherently subjective, and characteristics of the sample must be considered when reflecting on the results [50]. Due to the inclusion criteria of the pilot study, our qualitative results only reflect the views of a selected population of patients without GP attachment. However, for context and potential contrast with a less selective patient sample, we can refer to a previous qualitative study by our research group [36]. The fact that only patients who had sufficient German language skills were able to take part in the study may also limit transferability to unselected ED users. Moreover, it must be stressed that GP attachment is not formalized (and therefore not associated with e.g. a registration process) in Germany, and ‘having a GP’ or not is a personal subjective definition for the individual patient. As described, part of our sample had made use of GP care in the recent past, but nevertheless participants described themselves as ‘unattached’ to a GP. Apart from the fact that our results reflect peculiarities of the German health care system with its absence of gatekeeping regulations, the urban study setting, as mentioned above, might also have distinctly impacted the results and limits the conclusions derived from it. This requires further research to correspondingly explore the issue in rural settings, for example.


Factors that contribute to non-utilization of GP care in low-acuity ED patients are multifaceted. Patients’ personal life situations, health literacy, and experiences with GPs, play an important role in their behavior when seeking medical care and choosing acute care options. As the themes identified were found to be interrelated, this study highlights individual non-utilization as a complex configuration, for which the insights derived from our data provide a framework useful for understanding and better description. This can be very helpful in targeting future intervention approaches to promote PC attachment and continuity of care and in turn strengthen GP-mediated health literacy. Our EMAPREPARE pilot intervention is a first step in this direction, providing both information material about alternative care paths and an optional GP appointment scheduling service [20].

Data Availability

The datasets used and analyzed in this study are available from the corresponding author upon reasonable request.



emergency department


primary care


general practitioner


Emergency and Acute Medicine Network for Health Care Research Berlin


Emergency and Acute Medicine– Primary Care Demands in Patients Resorting to Emergency Departments


Manchester Triage System


  1. Pines JM, Hilton JA, Weber EJ, Alkemade AJ, Al Shabanah H, Anderson PD, et al. International perspectives on Emergency Department Crowding. Acad Emerg Med. 2011;18(12):1358–70.

    Article  PubMed  Google Scholar 

  2. Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: a systematic review of causes, consequences and solutions. PLoS ONE. 2018;13(8):e0203316.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Scherer M, Lühmann D, Kazek A, Hansen H, Schäfer I. Patients attending emergency departments. Dtsch Arzteblatt Int. 2017;114(39):645–52.

    Google Scholar 

  4. Parkinson B, Meacock R, Checkland K, Sutton M. Clarifying the concept of avoidable emergency department attendance. J Health Serv Res Policy. 2021;26(1):68–73.

    Article  PubMed  Google Scholar 

  5. Carter EJ, Pouch SM, Larson EL. The relationship between Emergency Department crowding and patient outcomes: a systematic review. J Nurs Scholarsh. 2014;46(2):106–15.

    Article  PubMed  Google Scholar 

  6. Minderhout RN, Venema P, Vos HMM, Kant J, Bruijnzeels MA, Numans ME. Understanding people who self-referred in an emergency department with primary care problems during office hours: a qualitative interview study at a Daytime General Practice Cooperative in two hospitals in the Hague, the Netherlands. BMJ Open. 2019;9(6):e029853.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Oslislo S, Kümpel L, Cantu RR, Möckel M, Heintze C, Holzinger F. Bin Ich ein Notfall? Notfallempfinden und Entscheidungskompetenz in akuten Situationen: eine qualitative Erhebung bei Notaufnahmepatient*innen. Z Evid Fortbild Qual Gesundhwes. 2021;165:43–50.

    Article  PubMed  Google Scholar 

  8. Balakrishnan MP, Herndon JB, Zhang J, Payton T, Shuster J, Carden DL. The Association of Health Literacy With Preventable Emergency Department Visits: A Cross-sectional Study. Acad Emerg Med. 2017;24(9):1042–50.

  9. Wehler M, Kalch A, Bilandzic H, Händl T. Gesundheitskompetenz und Notfallverhalten. Notf Rettungsmedizin. 2022;25(6):427–33.

    Article  Google Scholar 

  10. Strauß A, Zimmermann T, Schäfer I, Scherer M. Gesundheitskompetenz und Hausarztbindung nicht dringlicher Patientinnen und Patienten in Notaufnahmen: Ergebnisse Der PiNo-Studie in Hamburg Und Schleswig-Holstein. Z Evid Fortbild Qual Gesundhwes. 2022;175:50–8.

    Article  PubMed  Google Scholar 

  11. Hansen H, Schäfer I, Porzelt S, Kazek A, Lühmann D, Scherer M. Regional and patient-related factors influencing the willingness to use general practitioners as coordinators of the treatment in northern Germany - results of a cross-sectional observational study. BMC Fam Pract. 2020;21(1):110.

    Article  PubMed  PubMed Central  Google Scholar 

  12. van den Berg MJ, van Loenen T, Westert GP. Accessible and continuous primary care may help reduce rates of emergency department use. An international survey in 34 countries. Fam Pract. 2016;33(1):42–50.

    Article  PubMed  Google Scholar 

  13. Willson KA, Lim D, Toloo G, FitzGerald G, Kinnear FB, Morel DG. Potential role of general practice in reducing emergency department demand: a qualitative study. Emerg Med Australas. 2022;34(5):717–24.

  14. Pak A, Gannon B. Do access, quality and cost of general practice affect emergency department use? Health Policy. 2021;125(4):504–11.

    Article  PubMed  Google Scholar 

  15. Wensing M, Szecsenyi J, Laux G. Continuity in general practice and hospitalization patterns: an observational study. BMC Fam Pract. 2021;22(1):21.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Adamczyk C, Huber M, Engelbrecht C, Kowalski L, Sanftenberg L, Schelling J, et al. Der Hausarzt als Koordinator Im Notfallsystem / the Family Physician: a coordinator in the Emergency System. Z Allg Med. 2019;5/2019:203–7.

    Article  Google Scholar 

  17. Tillmann J, Puth MT, Frank L, Weckbecker K, Klaschik M, Münster E. Determinants of having no general practitioner in Germany and the influence of a migration background: results of the German health interview and examination survey for adults (DEGS1). BMC Health Serv Res. 2018;18(1):755.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Busse R, Blümel M, Knieps F, Bärnighausen T. Statutory health insurance in Germany: a health system shaped by 135 years of solidarity, self-governance, and competition. Lancet. 2017;390(10097):882–97.

    Article  PubMed  Google Scholar 

  19. Afilalo J. Nonurgent Emergency Department Patient Characteristics and barriers to primary care. Acad Emerg Med. 2004;11(12):1302–10.

    Article  PubMed  Google Scholar 

  20. Kümpel L, Oslislo S, Resendiz Cantu R, Möckel M, Heintze C, Holzinger F. Exploring the views of low-acuity emergency department consulters on an educational intervention and general practitioner appointment service: a qualitative study in Berlin, Germany. BMJ Open. 2023;13(4):e070054.

    Article  PubMed  PubMed Central  Google Scholar 

  21. German Clinical Trials Register. Emergency and Acute Medicine - Primary Care demands in patients resorting to emergency departments [Internet]. DRKS00023480;

  22. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–51.

    Article  PubMed  Google Scholar 

  23. Gräff I, Goldschmidt B, Glien P, Bogdanow M, Fimmers R, Hoeft A, et al. The German version of the Manchester Triage System and its Quality Criteria– First Assessment of Validity and Reliability. PLoS ONE. 2014;9(2):e88995.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Robinson OC. Sampling in interview-based qualitative research: a theoretical and practical guide. Qual Res Psychol. 2014;11(1):25–41.

    Article  Google Scholar 

  25. Merriam SB, Tisdell EJ. Qualitative research: a guide to design and implementation. Fourth edition. San Francisco, CA: John Wiley & Sons; 2015. 1 p.

  26. Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52(4):1893–907.

    Article  PubMed  Google Scholar 

  27. Mayring P. Qualitative content analysis: theoretical foundation, basic procedures and software solution. Klagenfurt: Beltz; 2014.

    Google Scholar 

  28. Uscher-Pines L, Pines J, Kellermann A, Gillen E, Mehrotra A. Deciding to visit the Emergency Department for non-urgent conditions: a systematic review of the literature. Am J Manag Care. 2013;19(1):47–59.

    PubMed  PubMed Central  Google Scholar 

  29. Dinh MM, Berendsen Russell S, Bein KJ, Chalkley DR, Muscatello D, Paoloni R, et al. Statewide retrospective study of low acuity emergency presentations in New South Wales, Australia: who, what, where and why? BMJ Open. 2016;6(5):e010964.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Hoffmann F, Habbinga K. Notaufnahmebesuche Von Pflegeheimbewohnern: Analyse von Routinedaten einer städtischen Klinik der Schwerpunktversorgung. Med Klin Intensivmed Notfmed. 2023;118(7):549–55.

    Article  PubMed  Google Scholar 

  31. Schmiedhofer M, Möckel M, Slagman A, Frick J, Ruhla S, Searle J. Patient motives behind low-acuity visits to the emergency department in Germany: a qualitative study comparing urban and rural sites. BMJ Open. 2016;6(11):e013323.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Frederiksen HB, Kragstrup J, Dehlholm-Lambertsen B. Attachment in the doctor-patient relationship in general practice: a qualitative study. Scand J Prim Health Care. 2010;28(3):185–90.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Durand AC, Palazzolo S, Tanti-Hardouin N, Gerbeaux P, Sambuc R, Gentile S. Nonurgent patients in emergency departments: rational or irresponsible consumers? Perceptions of professionals and patients. BMC Res Notes. 2012;5(1):525.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Korczak V, Yakubu K, Angell B, Middleton P, Dinh M, Lung T, et al. Understanding patient preferences for emergency care for lower triage acuity presentations during GP hours: a qualitative study in Australia. BMC Health Serv Res. 2022;22(1):1442.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Wong CY, Hall J. Does patients’ experience of general practice affect the use of emergency departments? Evidence from Australia. Health Policy. 2018;122(2):126–33.

    Article  PubMed  Google Scholar 

  36. Oslislo S, Heintze C, Möckel M, Schenk L, Holzinger F. What role does the GP play for emergency department utilizers? A qualitative exploration of respiratory patients’ perspectives in Berlin, Germany. BMC Fam Pract. 2020;21(1):154.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Wehler M, Kalch A, Bilandzic H, Händl T. Gesundheitskompetenz und Notfallverhalten. Notf Rettungsmedizin. 2022;25:427-33.

  38. Herndon JB, Chaney M, Carden D. Health Literacy and Emergency Department Outcomes: a systematic review. Ann Emerg Med. 2011;57(4):334–45.

    Article  PubMed  Google Scholar 

  39. Oedekoven M, Herrmann WJ, Ernsting C, Schnitzer S, Kanzler M, Kuhlmey A, et al. Patients’ health literacy in relation to the preference for a general practitioner as the source of health information. BMC Fam Pract. 2019;20(1):94.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Himmel W, Dieterich A, Kochen MM. Will German patients accept their family physician as a gatekeeper? J Gen Intern Med. 2000;15(7):496–502.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Henninger S, Spencer B, Pasche O. Deciding whether to consult the GP or an emergency department: a qualitative study of patient reasoning in Switzerland. Eur J Gen Pract. 2019;25(3):136–42.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Sandvik H, Hetlevik Ø, Blinkenberg J, Hunskaar S. Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway. Br J Gen Pract. 2022;72(715):e84–90.

    Article  PubMed  Google Scholar 

  43. Wong AH, Ray JM, Eixenberger C, Crispino LJ, Parker JB, Rosenberg A, et al. Qualitative study of patient experiences and care observations during agitation events in the emergency department: implications for systems-based practice. BMJ Open. 2022;12(5):e059876.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Pereira Gray DJ, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors—a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open. 2018;8(6):e021161.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Wolinsky FD, Bentler SE, Liu L, Geweke JF, Cook EA, Obrizan M, et al. Continuity of care with a primary care physician and mortality in older adults. J Gerontol Biol Sci Med Sci. 2010;65A(4):421–8.

    Article  Google Scholar 

  46. OECD. Primary Care in Denmark [Internet]. OECD. 2017. (OECD Reviews of Health Systems).

  47. Erlingsson C, Brysiewicz P. A hands-on guide to doing content analysis. Afr J Emerg Med. 2017;7(3):93–9.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Mruck K, Breuer F. Subjectivity and reflexivity in qualitative research—the FQS issues. Forum Qual Soc Res. 2003;4(2).

  49. Paulhus DL. Socially desirable responding on Self-Reports. In: Zeigler-Hill V, Shackelford TK, editors. Encyclopedia of personality and individual differences. Springer International Publishing; 2017.

  50. Vasileiou K, Barnett J, Thorpe S, Young T. Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period. BMC Med Res Methodol. 2018;18(1):148.

    Article  PubMed  PubMed Central  Google Scholar 

Download references


We would like to thank all patients who participated in our study and the study team for their persistent recruitment efforts at the ED.


This study is funded by the Federal Ministry of Education and Research (BMBF), grant number 01GY1914. The funding body had no role in the design and conduct of the study, data collection, analysis, and interpretation of the data, or in the preparation, review and approval of the manuscript. We acknowledge financial support from the Open Access Publication Fund of Charité– Universitätsmedizin Berlin.

Open Access funding enabled and organized by Projekt DEAL.

Author information

Authors and Affiliations



M.M. initiated the network EMANet and is the principal investigator and speaker of the network. S.O. (health scientist), F.H. (GP and senior researcher), R.R.C. (ED physician) and C.H. (GP and senior researcher) designed the subproject EMAPREPARE. S.O., F.H. and R.R.C. developed the study protocol and research questions for the qualitative study module. S.O and L.K. (health scientists) developed the interview guide. L.K. and S.O. carried out the interviews and transcribed audio files. L.K. and S.O. analyzed and interpreted the data. L.K. drafted the manuscript for this paper. S.O., F.H., R.R.C., C.H. and M.M. critically revised the manuscript. All the authors have read and approved the final version of this manuscript. All authors qualify as authors according to ICMJE guidelines.

Corresponding author

Correspondence to Lisa Kümpel.

Ethics declarations

Ethics approval and consent to participate

The ethics committee of Charité– Universitätsmedizin Berlin approved the EMAPREPARE study (EA1/120/20). Written informed consent was obtained from all study participants, and methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary Material 2

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kümpel, L., Oslislo, S., Resendiz Cantu, R. et al. “I do not know the advantages of having a general practitioner” - a qualitative study exploring the views of low-acuity emergency patients without a regular general practitioner toward primary care. BMC Health Serv Res 24, 629 (2024).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: